CPT CODE and Description
97110 – Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility – average fee payment- $30 – $40
97113 – Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises
97116 – Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing)
The most common service provided by physical therapists in outpatient settings and billed to the Medicare program under the Part B benefit is therapeutic exercise (CPT® code 97110). The purpose of this article is to address claim billing errors and the Comprehensive Error Rate Testing (CERT) findings related to therapy procedure 97110 for insufficient documentation and incorrect coding.
Therapy code 97110 is a timed code and therefore subject to Medicare’s guidelines outlined in Chapter 5 of the “Medicare Claims Processing Manual,” Section 20.2 external pdf file. The guidelines apply to all timed services rendered to the patient in one session. First Coast Service Options (First Coast) provides the local coverage determination (LCD) ID L29289 that includes documentation requirements for therapy services. Both of these resources should be used to ensure that your provider is documenting and billing 97110 correctly to prevent documentation errors, coding errors, and payment recoupment.
97110 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility:
* Therapeutic exercise is performed with a patient either actively, active-assisted, or passively (e.g., treadmill, isokinetic exercise, lumbar stabilization, stretching, strengthening). The exercise may be medically reasonable and necessary for a loss or restriction of joint motion, strength, functional capacity or mobility, which has resulted from a specific disease or injury.
* Documentation must show objective loss of joint motion, strength, or mobility (e.g., degrees of motion, strength grades, levels of assistance with exercise).
97113 Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises:
* This procedure uses the therapeutic properties of water (e.g., buoyancy, resistance). The procedure may be medically reasonable and necessary for a loss or restriction of joint motion, strength, mobility, or function that has resulted from a specific disease or injury. Documentation must show objective loss of joint motion, strength, or mobility (e.g., degrees of motion, strength grades, levels of assistance).
* This code should not be used in situations where no exercise is being performed in the water environment (e.g., debridement of ulcers).
* Other forms of exercise therapy may be medically necessary in addition to aquatic therapy when the patient cannot perform land-based exercises effectively to treat his/her condition without first undergoing the aquatic therapy, or when aquatic therapy facilitates progress to land-based exercise or increased function. Documentation must be available in the record to support medical necessity.
* It is not medically necessary to have more than one form of hydrotherapy (codes 97022, 97036, 97113) during the same visit.
97116 Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing):
* This procedure may be medically necessary for training patients whose walking abilities have been impaired by neurological, muscular or skeletal abnormalities or trauma.
* This procedure is not medically reasonable and necessary when the patient’s walking ability is not expected to improve.
* Repetitive walk-strengthening exercise for feeble or unstable patients or to increase endurance do not require provider supervision and will be denied as not reasonable and necessary.
* The medical record should document the distinct treatments rendered when gait training for a lower extremity is done during the same visit as orthotic fitting and training (97504), prosthetic training (97520), or self care/home management training (97535).
General Guidelines for Therapeutic Procedures 97110-97546: The following clinical guidelines pertain to the specific therapeutic procedures listed below. Please refer to the “ICD-9-CM Codes that Support Medical Necessity” section in this policy for appropriate covered diagnoses to be used with these therapeutic procedures.
1. Therapeutic procedures are procedures that attempt to reduce impairments and improve function through the application of clinical skills and/or services.
2. Use of these procedures requires that the practitioner have direct (one-on-one) patient contact. In physicians’ offices, the “incident to” provisions apply.
3. These procedures describe several different types of therapeutic intervention. The expected goals documented in the treatment plan, effected by the use of each of these procedures, will help define whether these procedures are medically reasonable and necessary. Therefore, since any one or a combination of more than one of these procedures may be used in a treatment plan, documentation must support the use of each code as it relates to a specific therapeutic goal.
4. For 97110-97112, treatment would not be expected to exceed 18 visits within an 8 week period.
5. Services provided concurrently by a physician, physical therapist and occupational therapist may be covered if separate and distinct goals are documented in the treatment plans.
6. For 97110, 97116, 97532, 97533, 97535 and 97537: A Medicare beneficiary with vision loss may be eligible for rehabilitation services designed to improve functioning, by therapy, to improve performance of activities of daily living, including self-care and home management skills. Evaluation of the patient’s level of functioning in activities of daily living, followed by implementation of a therapeutic plan of care aimed at safe and independent living, is critical and should be performed by an occupational or physical therapist. (Physical Therapy and Occupational Therapy assistants cannot perform such evaluations.)
Insufficient documentation errors
Insufficient documentation is the leading cause of CERT errors for First Coast. Below are examples of insufficient documentation determined by the CERT contractor when reviewing outpatient therapy documentation:
• Missing total time spent in therapy
• Missing billing provider signed and dated treatment notes
• Missing plan of care or plan of treatment
• Missing progress notes that support medical necessity
LCD documentation requirements
• Therapy services must relate directly and specifically to a written treatment plan. The plan must be established before treatment is begun.
• The signature and professional identity of the person who established the plan, and the date it was established must be recorded with the plan.
• The plan of care shall contain, at minimum, the following information:
• Diagnosis
• Long term treatment goals; and
• Type, amount, duration and frequency of therapy services
• The progress report provides justification for the medical necessity of treatment. Contractors shall determine the necessity of services based on the delivery of services as directed in the plan and as documented in the treatment notes and progress report.
• Documentation for therapeutic exercise (97110) must show objective loss of joint motion, strength, mobility (e.g., degrees of motion, strength grades, level of assistance, etc.).
• Therapeutic exercise is considered medically necessary if at least one of the following conditions is present and documented:
• The patient has weakness, contracture, stiffness secondary to spasm, spasticity, decreased range of motion, gait problem, balance and/or coordination deficits, abnormal posture, muscle imbalance; or
• The patient needs to improve mobility, stretching, strengthening, coordination, control of extremities, dexterity, range of motion, or endurance as part of activities of daily living training, or re-education.
• Total treatment minutes of the patient, including those minutes of active treatment reported under the timed codes and those minutes represented by the untimed codes, must be documented.
Billing for timed codes
Incorrect coding is the second leading cause of CERT errors for outpatient therapy services. An incorrect coding error is assessed if the correct number of units is not reported according to the documentation received. If a service represented by a 15-minute timed code is performed in a single day for at least 15 minutes, bill that service as one unit. If the service is performed for at least 30 minutes, bill that service as two units.
It is not appropriate to count all minutes of treatment in a day toward the units for one code if other services were performed for more than 15 minutes. When more than one service represented by 15-minute timed codes is performed in a single day, the total number of minutes of service determines the number of timed units billed. Total treatment time does not include time for services that are not billable (e.g, rest periods).
If any 15-minute timed service performed for seven minutes or less on the same day as another 15-minute timed service also performed for seven minutes or less, and the total time of the two is eight minutes or greater, bill one unit for the service performed for the most minutes. Apply the same logic when three or more different services are provided for seven minutes or less.
The expectation is that a therapist’s direct patient contact time for each unit will average 15 minutes in length. If a therapist has a consistent practice of billing less than 15 minutes for a unit, these situations could become subject for review. If more than one 15-minute timed CPT® code is billed during a single calendar day, the total number of timed units that can be billed is constrained by the total treatment minutes for that day.
Example No. 1
8 minutes of therapeutic exercise (97110)
8 minutes of manual therapy (97140)
Total = 16 timed minutes
The appropriate billing in this example is one unit. You should select 97110 or 97140 to bill because each unit was performed for the same amount of time and only one unit is allowed.
Example No. 2
33 minutes of therapeutic exercise (97110)
7 minutes of manual therapy (97140)
Total = 40 timed minutes
The appropriate billing in this example is three units. Bill two units of 97110 and one unit of 97140, and count the first 30 minutes of 97110 as two full units. Compare the remaining time for 97110 (33-30 = 3 minutes) to the time spent on 97140 (7 minutes) and bill the larger, which is 97140.
Coverage Indications, Limitations, and/or Medical Necessity
NOTE: Notations are made throughout this LCD on where to find additional information and complete discussions on the topics outlined in this LCD. Providers should refer to these manuals for additional information not discussed in this LCD.
ACTIVE PARTICIPATION of the clinician in treatment means that the clinician personally furnishes in its entirety at least one billable service on at least one day of treatment.
ASSESSMENT is separate from evaluation and is included in services or procedures (it is not separately reimbursable).
CERTIFICATION is the physicianns/nonphysician practitionerrs (NPP) approval of the plan of care. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.
INTERVAL of certified treatment (certification interval) consists of 90 calendar days or less, based on an individualls need. A physician/NPP may certify a plan of care for an interval length that is less than 90 days. There may be more than one certification interval in an episode of care. The certification interval is not the same as a Progress Report period.
TREATMENT DAY means a single calendar day on which treatment, evaluation and/or re-evaluation is provided. There could be multiple visits, treatment sessions/encounters on a treatment day.
Therapeutic Exercise (CPT code 97110)
Therapeutic exercise is performed on dry land with a patient either actively, active-assisted, or passively participating (e.g., treadmill, isokinetic exercise, lumbar stabilization, stretching, strengthening).
Therapeutic exercise is considered medically necessary if at least one of the following conditions is present and documented: the patient having weakness, contracture, stiffness secondary to spasm, spasticity, decreased range of motion, gait problem, balance and/or coordination deficits, abnormal posture, muscle imbalance, or the patient needing to improve mobility, stretching, strengthening, coordination, control of extremities, dexterity, range of motion, or endurance as part of activities of daily living training, or re-education.
Reimbursement Guidelines
Documentation Requirements – Timed Therapeutic Intervention
Optum will align timed therapeutic treatment documentation requirements with the American Physical Therapy Association’s Defensible Documentation for Patient/Client Management document and Centers for Medicare and Medicaid Services (CMS) National Policy.
The CPT section devoted to “therapeutic procedures” contains many of the CPT codes utilized by rehabilitation providers to describe the skilled, direct one-on-one component of treatment. These codes describe the bulk of hands-on, skilled care typically provided by rehabilitation providers.
CPT defines Therapeutic Procedures 97110-97140, 97530-97542, 97750-97762 as follows:
• A manner of effecting change through the application of clinical skills and/or services that attempt to improve function.
• Physician or therapist required to have direct (one-on-one) patient contact.
• Therapeutic procedure, one or more areas, each 15 minutes;
Additionally, the definition of CPT codes 97750-97755, Therapeutic Procedures, Tests and Measurement includes, “with written report, each 15 minutes.”
In the case of the timed therapeutic CPT codes, documentation should reflect the thought process and skilled decision making of the licensed therapy provider. As such, documentation of patient/client care needs to be more than a litany of procedures related to a date of service. Documentation must include evidence of knowledge and skill related to the procedures performed. It also should provide verification of professional judgment. This concept of clinical decision making can be incorporated into clinical documentation.
cpt 97110 modifier gp
The following codes are included below for informational purposes only, and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply subscriber coverage or provider reimbursement.
CPT/HCPCS Modifier: 25, GP
ICD Diagnosis: N/A
ICD Procedure: N/A
HCPCS: 97001-97799
The GN, GO, or GP therapy modifiers are currently required to be appended to therapy services. In addition to the KX modifier, the GN, GP and GO modifiers shall continue to be used. Providers may report the modifiers on claims in any order. If there is insufficient room on a claim line for multiple modifiers, additional modifiers may be reported in the remarks field.
The Centers for Medicare and Medicaid Services (CMS) implemented a new claimsbased data collection requirement for outpatient therapy services. CMS requires reporting with 42 new non payable functional G-codes and 7 new modifiers on claims for Physical Therapy
(PT), Occupational Therapy (OT) and Speech Language Pathology (SLP) services. As part of the change, CMS is again requiring the GP, GO & GN modifiers be billed for informational purposes. To align with CMS’s change, we will implement this requirement to allow for consistency in claims processing.
There are two exceptions that exist when functional reporting is required on a claim for therapy services.
1. Therapy services under more than one therapy Plan of Care (POC). Claims may contain more than two non-payable functional G-codes in cases where a beneficiary receives therapy services under multiple POCs (PT, OT, and/or SLP) from the same therapy provider.
2. One-Time Therapy Visit. When a beneficiary is seen and future therapy services are either not medically indicated or are going to be furnished by another provider, the clinician reports on the claim for the DOS of the visit, all three G-codes in the appropriate code set (current status, goal status and discharge status), along with corresponding severity modifiers.
Each reported functional G-code must also contain the functional therapy modifier indicating the discipline of the POC – GP, GO or GN for PT, OT & SLP. Therapy claims billed without the appropriate therapy modifier (GP, GO, GN) will be denied as a billing error.
To be considered for reimbursement, claims must identify the specific therapy type. Claims for PT services must include modifier GP, and claims for OT services must include modifier GO. Evaluation and reevaluation procedure codes do not require the modifiers. Outpatient therapy services provided by a physical or occupational therapist or by an outpatient facility must be submitted to TMHP in an approved electronic format or on a CMS-1500 paper claim form.
